Mental health articles

Conceptualization and diagnosis of sexual victimization Conceptualization and diagnosis are complicated, since individuals’ reactions,
the length of the distress, and events vary widely. Th e ecological model developed
by Koss and Harvey (1991) accounts for the multiple factors that impact
victims’ responses. Initially applied to rape trauma, the model fi ts other forms
of sexual victimization as well. Th e model considers interrelationships among
personal characteristics of the victim (e.g., age, developmental stage), aspects
of the traumatic event (e.g., duration, severity), and the social environment
in which recovery occurs (e.g., social supports, attitudes, and values). It also
accommodates multicultural considerations (e.g., race, ethnicity, class, and
sexual orientation) identifi ed by Sue and Sue (2003) as important variables
aff ecting clients’ response.
Since rape, sexual assault, and other forms of interpersonal violence represent
traumatic events that overwhelm ordinary functioning (Herman,
1992), the diagnosis of posttraumatic stress disorder (PTSD) is a useful way
to conceptualize many victims of abuse (American Psychiatric Association,
2000). People who have PTSD respond to the traumatic event with intense
fear, helplessness, horror, reexperiencing of the event, and oft en other symptoms
such as numbing or increased arousal, persistent avoidance of stimuli
associated with the trauma, and signifi cant disturbance in functioning.
PTSD may be acute (less than 3 months), chronic (3 months or longer), or of
delayed onset (a minimum of 6 months). Symptoms presenting and resolving
within 4 weeks of the traumatic event have the diff erential diagnosis of acute
stress disorder (ASD).
Complex PTSD may be presented by those who have been repeatedly subjected
to traumatic experiences (Herman, 1992). Th ese people experience
problems with trust, overwhelming emotions, destructive behaviors, identity
confusion, and dissociation. Brown (2003) notes that traumatic experiences
may fi t broader defi nitions than the standard diagnoses in the Diagnostic
and Statistical Manual (DSM) (American Psychiatric Association, 2000),
including events or experiences that violate a person’s expectations of a just
or safe world, betray trust in dependency relationships, or occur as a buildup
of small, persistent threats. Now considered a subcategory of PTSD, another
useful diagnosis is rape trauma syndrome, fi rst introduced by Burgess and
Holmstrom (1974). Rape trauma syndrome is characterized by consistent
psychological reactions that come fi rst in an acute phase (lasting from several hours to several weeks), and then in a reorganization phase (the long-term
process of recovery, including chronic disturbances).
Th e patterns of response to sexual victimization seen in rape trauma syndrome
have been described by several other authors (Koss & Harvey, 1991;
Sutherland & Scherl, 1970; Walker, 1994). Koss and Harvey describe four
phases of response: (1) anticipation, or the earliest recognition of danger,
(2) impact of the event and its immediate aft ermath, (3) reconstitution, or
attending to basic living considerations and outwardly adjusting despite
ongoing symptoms, and (4) resolution. Th ese phases do not necessarily play
out in a smooth or predictable steplike progression. During the reconstitution
phase, which varies from a few weeks to several months, the victim
may experience anxiety, fearfulness, nightmares, depression, guilt, shame,
sexual dysfunction, somatic complaints, and helplessness. Ideally, the victim
is eventually able to seek help; identify anger; have altered cognitive
schemas; experience safety, trust, power, and esteem; enjoy intimacy; and
develop resilience. Unfortunately, for some, resolution is long delayed or
may not occur.
While some students present directly with sexual victimization, commonly
other problems are identifi ed as the primary concern: alcohol or
substance abuse, eating disorders, depression, anxiety, diffi culty in relationships,
dissociation, or self-mutilation. Sexual victimization may have
happened a long time ago and not have been considered victimization by
the client and/or not have been recognized as being connected to current
problems (Koss & Harvey, 1991); therefore, to recognize and treat sexual
victimization, routine screening and questioning about experiences, using
specifi c, nonjudgmental language, is essential. Th e case of Laurel illustrates
how other presenting issues can disguise sexual victimization.